MEDICARE: DR. JORDAN LEE BALES M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	MD16885	HI
2	207P00000X	Emergency Medicine Physician	61140-20	WI
3	207P00000X	Emergency Medicine Physician	MD29300	OR
4	207P00000X	Emergency Medicine Physician	26695	NE
5	207P00000X	Emergency Medicine Physician	10934	ND
6	207P00000X	Emergency Medicine Physician	58995	TN
7	207P00000X	Emergency Medicine Physician	P9153	TX

General Provider Information

NPI Number	:	1760691927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN LEE BALES M.D.

Provider Business Mailing Address
First Line	:	3905 PRINE LN
Second Line	:
City	:	DEER PARK
State	:	TX
Zip	:	77536-2030
Country	:	US
Telephone Number	:	541-220-1268
Fax Number	:

Provider Business Practice Location Address
First Line	:	3107 EDGAR BROWN DR
Second Line	:
City	:	WEST ORANGE
State	:	TX
Zip	:	77630-5347
Country	:	US
Telephone Number	:	409-920-4470
Fax Number	:	409-920-4475

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	05/07/2019

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